The Monday Memo
September 24, 2018 PITT DPT STUDENTS
Imagine the average outpatient orthopedic patient that comes in to your clinic. In many cases, this patient is middle-aged, give or take, with non-traumatic subacute or chronic musculoskeletal pain or pain with acute onset from a seemingly benign cause related to activities of daily living. Picture the out of shape, overweight, oftentimes frail patient whose goal is to simply return to navigating stairs and putting dishes into an overhead cabinet without pain. Or the patients with nagging back or neck pain who sit for 10 hours per day and are lucky if they get 5,000 steps in, let alone a productive strength training session. They present with global weakness, especially in the core stabilizers of the spine, hips and shoulders. Manual muscle testing of the glutes and rotator cuff are all 3/5, and don’t even get me started on what their single leg squats and lateral step downs look like. So we create an exercise program to address these strength and motor control deficits. We do a little manual therapy, grab some therabands and durabands for preliminary strengthening, toss an ankle weight or two into the patient’s table exercises, hit some machines, and then finally get into good stuff like squatting and deadlifting mechanics to optimize the patient’s function. When we’re really feeling crazy, we’ll throw a 15 pound dumbbell into the mix to increase the difficulty in the latter stages of the program. If we’re lucky, we might even see a droplet of sweat or two begin to appear on the patient’s brows.
After a few weeks of this approach the patient’s pain diminishes and their functional ability begins to return. We educate them on the importance of exercise and maybe even give them a maintenance program for them to stick with as we send them on their merry way. They stick with the maintenance program for a time, but after a short period they begin to find the band, plank, and dumbbell exercises to be boring and ultimately abandon them. They return to their routine of sitting 10 hours per day. Life begins to creep back to its normal daily grind, work and family-related stresses spike, and suddenly the patient’s pain starts to rear its ugly head once again. The cycle continues.
This story should sound all-too-familiar to many of us working in the average outpatient orthopedic clinic. We achieve good short-term results, but once the patient falls back into their previous lifestyle patterns, their previous pain returns or some new pain emerges. We become the liposuction of rehab; we suck the proverbial fat from the patient by giving them some targeted exercises, but then they return to their prior unhealthy diets consisting of sedentary behavior and quickly find that they were right back where they started before treatment. We generally are not doing a good enough job at instructing and inspiring patients to change their behavior to get active and get strong. Many of the exercises we prescribe and equipment we use in the clinic do not translate to the behavioral changes necessary to create a lasting effect. We can’t achieve long-term outcomes unless we change behavior.
One solution staring us in the face is to include equipment like barbells and kettlebells in our clinics. On one hand, this equipment helps to enforce functional, compound movements in the context of loads that are not currently attainable in the standard clinic but may be encountered by the patient in daily life. Unlike machines, this equipment allows for multiplanar and, as is often the case with kettlebells, unorthodox movements that better replicate the variable demands placed on the body in daily life. What is perhaps more important, however, is that by putting this equipment in the hands of our patients and educating them on how to use it safely, we are diffusing the stigma and fear surrounding squats, deadlifts, swings, and other crucial fundamental exercises associated with barbells and kettlebells. By reducing fear and increasing awareness of the benefits of this kind of physical training, we are empowering our patients to take control of their own health by adjusting their lifestyles to include barbell and kettlebell training as a regular staple rather than regressing to their previous sedentary behavior. If we incorporate this into our treatment paradigm (and offer cash-based strength and conditioning services to compound the effects of rehab), we will likely see meaningful behavioral changes from our patients that will in turn lead to the longstanding pain reduction and functional outcomes that we are currently striving toward in our practices.
Don’t be the liposuction of rehab. Demand excellence out of your patients, your clinic, and yourself by making barbell and kettlebell training part of rehab culture.
-Brooks Kenderdine, SPT
The Monday Memo
September 17, 2018 PITT DPT STUDENTS
In the course of my first two years in PT school there was one constant message that transcended our entire curriculum: the importance of patient education. Whether my classmates and I were practicing transfer skills, reviewing examination components, role-playing exercise instruction, planning hypothetical discharges, or simulating gait training, our professors never ceased to mention how imperative it is for us to properly teach and inform our patients through their duration of care.
The consistency to which patient education was harped on in school mirrors how frequently I attempt weave it into my own patients’ plans of care. Every patient requires a certain level of exercise instruction and correction, but as I reflect on my clinical experience thus far I am conscious of how often the education I was providing had nothing to do with the right way to squat or perform a clamshell. Instead, I recall moments discussing affordable gym memberships, community resources, pathology and pain, and even fighting for the value of PT when patients verbalized a lack of motivation. Every conversation had value; however, one patient I treated exemplifies how essential this aspect of PT can be.
My patient had recently received the diagnosis of Multiple System Atrophy (MSA) and expressed to me a lack of understanding of the disease and what it meant for his future function. We spent time at the conclusion of the session that day discussing what the disease was, which symptoms he currently had, and I pointed him towards online resources and organizations that are dedicated to supporting the community of people impacted by MSA. While the conversation was not easy due to the prognosis, it was clear that the exchange had an overall positive impact on the patient. He expressed his gratitude and how he could see that the therapists involved in his care genuinely cared about his current and future health.
This patient epitomizes why education plays a vital role in the rehabilitative process and why it should be used to compliment the physical interventions we provide on a daily basis.
The Monday Memo
September 10, 2018 PITT DPT STUDENTS
Deadbug Anti-Extension Progression:
Moment Arms & Torque Production
Core stability is a hot topic in the world of physical therapy for good reason. Today’s video memo provides you with an example anti-extension progression, beginning with a basic, day 1 pelvic control drill (1⃣), & progressing towards weighted, higher level versions (4⃣/5⃣). Check out the video below and then tune in for a follow-up message below!
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EPISODE 212 | Trunk Anti-Extension Progression: Deadbug Variations . ▪️I really enjoy posting content similar to today’s video. . Why? . Because it’s JAM-PACKED with conceptual information. . This video provides you with a fairly complete anti-extension progression, beginning with a basic, day 1 pelvic control drill (1️⃣), & progresses you towards weighted, higher level versions (4️⃣/5️⃣) that I’ve used to challenge professional athletes. . I’ll post a follow up detailing each exercise, but let’s use today to touch on an important concept: TORQUE PRODUCTION & MOMENT ARMS! . . . 🤓TORQUE PRODUCTION & MOMENT ARMS! . Revisiting physics, we know that you can create more torque by using a wrench w/ a longer handle. . In essence, a longer wrench has a longer moment arm, which means a relative amount of torque can be produced w/ less force. . We can apply this to single-leg lowers & deadbugs by understanding that our leg is the moment arm upon which gravity exerts a force to produce torque at the hip & up the chain. . In response, we need to produce an equal amount of force w/ our abdominals to maintain spinal positioning. . . 💡When we straighten our knee or lower our leg further, we’re effectively increasing the moment arm, & since gravity pulls w/ the same amount of force, our abdominals must contract harder & produce more force to maintain the same position. . We can take it further by including our arms or lowering both legs at the same time. . . 💡Our arms add another element that gravity uses to create more extension force & focuses more on controlling rib cage, rather than pelvic, positioning. . Lowering both legs at once inc the mass & eliminates the rotational component created by the unilateral Deadbug. . . . 🔥This is an incredibly important concept to understand & can be applied to ALL therapeutic exercise. . It’s this kind of knowledge that allows you to adjust for the trainee in front of you & work w/ a wider range of patients/clients. . . ▪️Questions, comments, concerns? Drop a line in the section below! . Was this information helpful? Tag a friend & help spread the word! . #StoutTraining #DPTstudent #Physics . @stoutpgh @clinicalathlete @perform_better
It’s important to understand the underlying concept that allows this progression to be so effective: TORQUE PRODUCTION & MOMENT ARMS!
Revisiting physics, we know that TORQUE is a product of the FORCE APPLIED and the distance from the point of force application and the axis of rotation, or the MOMENT ARM. Think of a wrench! A wrench with a longer handle allows you to create more torque with the same amount of force!
We can apply this to single-leg lowers & deadbugs by understanding that our leg is the moment arm upon which gravity acts. This produces torque applied at the hip which is transmitted up the chain. In response, our musculature must produce an equal amount of force in order to maintain lumbopelvic position.
➢ When we straighten our knee or lower our leg further, we’re effectively increasing the moment arm, and our trunk musculature must contract harder & produce more force to maintain the same position.
We can take this further by including our arms or lowering both legs at the same time!. .
➢ Our arms add another point at which gravity act to create more extension force. The arms are a part of our upper quarter shifting the focus more towards controlling rib cage, rather than pelvic, positioning.
Lowering both legs at once increase the mass and eliminates the rotational component created when performing the unilateral Deadbug!
This is an important concept to understand and some critical thinking can help you apply it to ALL therapeutic exercise. It’s this kind of knowledge that allows you to adjust for the trainee in front of you, find success with a wider range of individuals, and enhance your abilities as a provider!
The Monday Memo
September 3, 2018 PITT DPT STUDENTS
Recently, some Pitt DPT students have had the opportunity to work with athletes that participate in the sport of handcycling. These athletes have tremendous endurance and conquer unbelievable physical feats such as completing marathons in sub 2 hour times. Below is some background on the sport for anyone interested in learning more about handcycling.
Types of Handcycles
- An upright handcycle is an entry-level bike for those who are new to the sport, who just want exercise or recreation, or who don’t want to ride very long distances or go very fast. Because of their higher center of gravity, upright handcycles aren’t suitable for speeds higher than 15 mph.
- A recumbent handcycle, borrowed from the cycling industry, usually come in a choice of three or seven speeds, which naturally limits the speed to less than 15 mph. They are easy to transfer in and out of from a wheelchair, and have a natural, fork-type steering system.
Recumbent handcycles come in a few different variations. There are two steering options: fork-steer and lean-to-steer, and two seating options: one where the rider reclines and the other, a “trunk-power” version, where the rider leans forward. They usually come with 27-gear drivetrains, although they can be purchased with three- or seven-gear drivetrains.
- The trunk-power handcycle doesn’t have much of a seatback. The cranks are low to the ground and far away from the rider. With this arrangement, riders are able to put the weight of their trunks behind each stroke, allowing them to go faster for longer. The limitation to this type of handcycle, Lawless said, is that the athlete must have control of most or all of his abdominal muscles.
With the other seating option, the rider sits in a seat with a reclined back. The cranks are higher and closer, allowing the rider to use the seatback for leverage to rotate the cranks.
Hand Cycling Classifications
- The most severe of this class grouping, H1 is reserved for the most severe quadriplegics and those who have impairments with equivalent limitations. These athletes compete in a recumbent (reclined) position.
- Lesion/impairment: C6
- Cycle used: AP2, AP3
- H2 is for quadriplegic (and equivalent) athletes with more arm power than those in H1. These athletes compete in a recumbent (reclined) position.
- Lesion/impairment: C7-T3
- Cycle used: AP2, AP3
- H3 is for athletes with varying impairments, including paraplegia, triplegia and hemiplegia. These athletes compete in a recumbent (reclined) position.
- Lesion/impairment: T4-T10
- Cycle used: AP2, AP3, ATP2
- H4 athletes may have impairments, such as paraplegia, similar to but more moderate than athletes in H3. These athletes have full or almost full trunk control, and they compete in a recumbent (reclined) position. These athletes might also compete with a trunk propelled hand cycle.
- Lesion/impairment: T11 down, and amputees unable to knee
- Cycle used: AP2, AP3, ATP2
- H5 is for athletes who can compete kneeling. These athletes usually have severe impairments of the legs, such as paraplegia or amputations, but have almost full control over their arms and trunk. These athletes compete in recumbent or trunk propelled hand cycle. Athletes with milder full-body disorders such as athetosis, but limited use of their legs, may also compete in H5.
- Lesion/impairment: T11 down(ability to kneel), and amputees with the ability to kneel
- Cycle used: kneeling
||Reclined to 30 degrees
||Reclined at 10 degrees
||Long sit position
- Bobby Jesmer, SPT
- Jim Tersak, SPT, CSCS